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Ioannidis P, Katsaras D, Zografos T, Charalambopoulos P, Kouvelas K, Tsitsinakis G, Raitsos-Exarchopoulos I, Kappou T, Zagoraios A, Ganas P, Vassilopoulos A, Xylakis E, Christoforatou E. Box Lesion Isolation of the Left Atrial Posterior Wall with Radiofrequency Ablation Restricted in Predetermined Lines for the Treatment of Persistent Atrial Fibrillation: The Prognostic Role of Acute Interventional Outcome and Trigger Identification. J Innov Card Rhythm Manag 2023; 14:5642-5653. [PMID: 38058389 PMCID: PMC10697114 DOI: 10.19102/icrm.2023.14115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/29/2023] [Indexed: 12/08/2023] Open
Abstract
The left atrial posterior wall (PW) is known to be a critical substrate for the initiation and perpetuation of atrial fibrillation (AF) and has been explored as a target for catheter ablation, particularly in persistent AF (PerAF). In this retrospective study, we investigate the clinical outcome of patients with PerAF who underwent PW isolation (PWI) restricted in predetermined lines in addition to pulmonary vein isolation (PVI). One hundred consecutive patients (64 ± 9.1 years, 66% male, 20% with previous PVI ablation) underwent PWI in a box lesion setting for PerAF lasting >3 months (34% long-standing PerAF). PW triggers were defined as either foci from the PW that repeatedly induced AF or as isolated AF or atrial tachycardia (AT) within the PW. After a mean follow-up period of 25.6 ± 6.7 months, 61% of the patients remained in sinus rhythm after the last procedure. In 79 patients, the PW was successfully isolated, while, in 21 patients, complete isolation was not possible due to failure in completion of the roof line (n = 16), the floor line (n = 7), or both (n = 2). Patients with incomplete isolation had similar AF/AT recurrence rates compared to those with complete PWI. In 12 patients, PW triggers were identified, and PWI in these patients was shown to have a significantly better prognosis in terms of sinus rhythm maintenance (P = .031). Failure of complete PWI does not predispose a patient to an inferior outcome nor is it responsible for iatrogenic ATs. The presence of AF triggers within the PW leads to a particularly favorable result after box lesion isolation.
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Kong MH, Castellano S, Ruppersberg P, Lizama KS, Avitall B. Visualization of electrographic flow fields of increasing complexity and detection of simulated sources during spontaneously persistent AF in an animal model. Front Cardiovasc Med 2023; 10:1223481. [PMID: 37719974 PMCID: PMC10503433 DOI: 10.3389/fcvm.2023.1223481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023] Open
Abstract
Background Mapping algorithms have thus far been unable to localize triggers that serve as drivers of AF, but electrographic flow (EGF) mapping provides an innovative method of estimating and visualizing in vivo, near real-time cardiac wavefront propagation. Materials and Methods One-minute unipolar EGMs were recorded in the right atrium (RA) from a 64-electrode basket catheter to generate EGF maps during atrial rhythms of increasing complexity. They were obtained from 3 normal, animals in sinus rhythm (SR) and from 6 animals in which persistent AF which was induced by rapid atrial pacing. Concurrent EGF maps and high-resolution bipolar EGMs at the location of all EGF-identified sources were acquired. Pacing was subsequently conducted to create focal drivers of AF, and the accuracy of source detection at the pacing site was assessed during subthreshold, threshold and high-output pacing in the ipsilateral or contralateral atria (n = 78). Results EGF recordings showed strong coherent flow emanating from the sinus node in SR that changed direction during pacing and were blocked by ablation lesions. Additional passive rotational phenomena and lower activity sources were visualized in atrial flutter (AFL) and AF. During the AF recordings, source activity was not found to be correlated to dominant frequency or f wave amplitude observed in concurrently recorded EGMs. While pacing in AF, subthreshold pacing did not affect map properties but pacing at or above threshold created active sources that could be accurately localized without any spurious detection in 95% of cases of ipsilateral mapping when the basket covered the pacing source. Discussion EGF mapping can be used to visualize flow patterns and accurately identify sources of AF in an animal model. Source activity was not correlated to spectral properties of f-waves in concurrently obtained EGMs. The locations of sources could be pinpointed with high precision, suggesting that they may serve as prime targets for focal ablations.
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Affiliation(s)
| | | | | | - Ken S. Lizama
- Deptartment of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Boaz Avitall
- Deptartment of Medicine, University of Illinois at Chicago, Chicago, IL, United States
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3
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Parra-Lucares A, Villa E, Romero-Hernández E, Méndez-Valdés G, Retamal C, Vizcarra G, Henríquez I, Maldonado-Morales EAJ, Grant-Palza JH, Ruíz-Tagle S, Estrada-Bobadilla V, Toro L. Tic-Tac: A Translational Approach in Mechanisms Associated with Irregular Heartbeat and Sinus Rhythm Restoration in Atrial Fibrillation Patients. Int J Mol Sci 2023; 24:12859. [PMID: 37629037 PMCID: PMC10454641 DOI: 10.3390/ijms241612859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Atrial fibrillation (AF) is a prevalent cardiac condition predominantly affecting older adults, characterized by irregular heartbeat rhythm. The condition often leads to significant disability and increased mortality rates. Traditionally, two therapeutic strategies have been employed for its treatment: heart rate control and rhythm control. Recent clinical studies have emphasized the critical role of early restoration of sinus rhythm in improving patient outcomes. The persistence of the irregular rhythm allows for the progression and structural remodeling of the atria, eventually leading to irreversible stages, as observed clinically when AF becomes permanent. Cardioversion to sinus rhythm alters this progression pattern through mechanisms that are still being studied. In this review, we provide an in-depth analysis of the pathophysiological mechanisms responsible for maintaining AF and how they are modified during sinus rhythm restoration using existing therapeutic strategies at different stages of clinical investigation. Moreover, we explore potential future therapeutic approaches, including the promising prospect of gene therapy.
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Affiliation(s)
- Alfredo Parra-Lucares
- Critical Care Unit, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- Cardiovascular Department, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Eduardo Villa
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | | | - Gabriel Méndez-Valdés
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Catalina Retamal
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Geovana Vizcarra
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Ignacio Henríquez
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | | | - Juan H. Grant-Palza
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Sofía Ruíz-Tagle
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | | | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- Centro de Investigación Clínica Avanzada, Hospital Clínico, Universidad de Chile, Santiago 8380420, Chile
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4
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Butcher C, Roney C, Wharmby A, Ahluwalia N, Chow A, Lambiase PD, Hunter RJ, Honarbakhsh S. In Atrial Fibrillation, Omnipolar Voltage Maps More Accurately Delineate Scar Than Bipolar Voltage Maps. JACC Clin Electrophysiol 2023; 9:1500-1512. [PMID: 37204357 DOI: 10.1016/j.jacep.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Optimal method for voltage assessment in AF remains unclear. OBJECTIVES This study evaluated different methods for assessing atrial voltage and their accuracy in identifying pulmonary vein reconnection sites (PVRSs) in atrial fibrillation (AF). METHODS Patients with persistent AF undergoing ablation were included. De novo procedures: voltage assessment in AF with omnipolar voltage (OV) and bipolar voltage (BV) methodology and BV assessment in sinus rhythm (SR). Activation vector and fractionation maps were reviewed at voltage discrepancy sites on OV and BV maps in AF. AF voltage maps were compared with SR BV maps. Repeat ablation procedures: OV and BV maps in AF were compared to detect gaps in wide area circumferential ablation (WACA) lines that correlated with PVRS. RESULTS Forty patients were included: 20 de novo and 20 repeat procedures. De novo procedure: OV vs BV maps in AF; average voltage 0.55 ± 0.18 mV vs 0.38 ± 0.12 mV; P = 0.002, voltage difference of 0.20 ± 0.07 mV; P = 0.003 at coregistered points and proportion of left atrium (LA) area occupied by low-voltage zones (LVZs) was smaller on OV maps (42.4% ± 12.8% OV vs 66.7% ± 12.7% BV; P < 0.001). LVZs identified on BV maps and not on OV maps correlated frequently to wavefront collision and fractionation sites (94.7%). OV AF maps agreed better with BV SR maps (voltage difference at coregistered points 0.09 ± 0.03 mV; P = 0.24) unlike BV AF maps (0.17 ± 0.07 mV, P = 0.002). Repeat ablation procedure: OV was superior in identifying WACA line gaps that correlated with PVRS than BV maps (area under the curve = 0.89, P < 0.001). CONCLUSIONS OV AF maps improve voltage assessment by overcoming the impact of wavefront collision and fractionation. OV AF maps correlate better with BV maps in SR and more accurately delineate gaps on WACA lines at PVRS.
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Affiliation(s)
- Charles Butcher
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Caroline Roney
- Queen Mary's University of London, London, United Kingdom
| | - Amy Wharmby
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Nikhil Ahluwalia
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Chow
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Pier D Lambiase
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Shohreh Honarbakhsh
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Queen Mary's University of London, London, United Kingdom.
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Vetta G, Parlavecchio A, Caminiti R, Crea P, Magnocavallo M, Della Rocca DG, Lavalle C, Vetta F, Marano G, Ruggieri C, Lofrumento F, Dattilo G, Ferraù L, Dell'Aera C, Giammello F, La Spina P, Musolino RF, Luzza F, Carerj S, Micari A, Di Bella G. Non-conducted premature atrial complexes: A new independent predictor of atrial fibrillation in cryptogenic stroke. J Electrocardiol 2022; 74:46-53. [PMID: 35964522 DOI: 10.1016/j.jelectrocard.2022.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/06/2022] [Accepted: 07/23/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the main cardiac cause of stroke, but it frequently remains undetected. In patients with cryptogenic stroke an Holter electrocardiogram (ECG) monitoring for AF is recommended. OBJECTIVE To evaluate the prognostic role of Non-Conducted Premature Atrial Complexes (ncPACs) recorded on Holter ECG. METHODS We prospectively enrolled consecutive patients admitted to the Stroke Unit of our hospital with a diagnosis of cryptogenic stroke between December 2018 and January 2020; all patients underwent 24-h Holter ECG monitoring during hospitalization. Two follow-up visits were scheduled, including a 24-h Holter ECG at 3 and 6 months to detect AF. RESULTS Among 112 patients, 58% were male with an average age of 72.2 ± 12.2 years. At follow-up, AF was diagnosed in 21.4% of the population. The baseline 24-h Holter ECG burden of ncPACs and Premature Atrial Complexes (PACs) was higher in patients with AF detected on follow-up (13.5 vs 2, p = 0.001; 221.5 vs 52; p = 0.01). ROC analysis showed that ncPACs had the best diagnostic accuracy in predicting AF (AUC:0.80; 95% CI 0.68-0.92). Cut-off value of ≥7 for ncPACs burden showed the highest accuracy with sensitivity of 62.5% and specificity 97.7% to predict AF onset at follow-up. Moreover, at multivariate Cox-proportional hazard analysis ncPACs burden ≥7 was a powerful independent predictor of AF onset (HR 12.4; 95% CI 4.8-32.8; p < 0.0001). CONCLUSIONS NcPACs burden ≥7 represents a new predictor of AF that could guide the screening of this arrhythmia in cryptogenic stroke patients.
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Affiliation(s)
- Giampaolo Vetta
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Antonio Parlavecchio
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rodolfo Caminiti
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Pasquale Crea
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, 00161 Rome, Italy; Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX 78705, USA
| | | | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | | | - Giovanni Marano
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Chiara Ruggieri
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesca Lofrumento
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Dattilo
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Ludovica Ferraù
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Cristina Dell'Aera
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Fabrizio Giammello
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paolino La Spina
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rosa Fortunata Musolino
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Luzza
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Scipione Carerj
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Micari
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Gianluca Di Bella
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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The Pathogenesis of Cardiac Arrhythmias in Vitamin D Deficiency. Biomedicines 2022; 10:biomedicines10061239. [PMID: 35740261 PMCID: PMC9220304 DOI: 10.3390/biomedicines10061239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/21/2022] [Accepted: 05/24/2022] [Indexed: 11/16/2022] Open
Abstract
The global prevalence of vitamin D deficiency is more than 20%, and the main causes include insufficient intake, reduced absorption, abnormal metabolism, or resistance to its effects. The levels of serum vitamin D appear to influence cardiovascular risk, and the mechanism involved is linked to the transient outward current and the ultrarapid delayed rectifier K+ current densities, activated through the nuclear vitamin D receptor and Akt pathway. A significant number of studies have correlated vitamin D deficiency with an increased risk of developing cardiac arrhythmias and sudden cardiac death. For this reason, the purpose of this review is to analyze the relation between vitamin D deficiency and the pathogenesis of cardiac arrhythmias. Atrial fibrillation, increased QT interval, and QT dispersion were the most common findings associated with vitamin D deficiency. Due to the heterogeneity among existing studies, further research is necessary to confirm the existing data and to analyze its relationship with other types of arrhythmias.
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7
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Chu GS, Li X, Stafford PJ, Vanheusden FJ, Salinet JL, Almeida TP, Dastagir N, Sandilands AJ, Kirchhof P, Schlindwein FS, Ng GA. Simultaneous Whole-Chamber Non-contact Mapping of Highest Dominant Frequency Sites During Persistent Atrial Fibrillation: A Prospective Ablation Study. Front Physiol 2022; 13:826449. [PMID: 35370796 PMCID: PMC8966840 DOI: 10.3389/fphys.2022.826449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Sites of highest dominant frequency (HDF) are implicated by many proposed mechanisms underlying persistent atrial fibrillation (persAF). We hypothesized that prospectively identifying and ablating dynamic left atrial HDF sites would favorably impact the electrophysiological substrate of persAF. We aim to assess the feasibility of prospectively identifying HDF sites by global simultaneous left atrial mapping. Methods PersAF patients with no prior ablation history underwent global simultaneous left atrial non-contact mapping. 30 s of electrograms recorded during AF were exported into a bespoke MATLAB interface to identify HDF regions, which were then targeted for ablation, prior to pulmonary vein isolation. Following ablation of each region, change in AF cycle length (AFCL) was documented (≥ 10 ms considered significant). Baseline isopotential maps of ablated regions were retrospectively analyzed looking for rotors and focal activation or extinction events. Results A total of 51 HDF regions were identified and ablated in 10 patients (median DF 5.8Hz, range 4.4-7.1Hz). An increase in AFCL of was seen in 20 of the 51 regions (39%), including AF termination in 4 patients. 5 out of 10 patients (including the 4 patients where AF termination occurred with HDF-guided ablation) were free from AF recurrence at 1 year. The proportion of HDF occurrences in an ablated region was not associated with change in AFCL (τ = 0.11, p = 0.24). Regions where AFCL decreased by 10 ms or more (i.e., AF disorganization) after ablation also showed lowest baseline spectral organization (p < 0.033 for any comparison). Considering all ablated regions, the average proportion of HDF events which were also HRI events was 8.0 ± 13%. Focal activations predominated (537/1253 events) in the ablated regions on isopotential maps, were modestly associated with the proportion of HDF occurrences represented by the ablated region (Kendall's τ = 0.40, p < 0.0001), and very strongly associated with focal extinction events (τ = 0.79, p < 0.0001). Rotors were rare (4/1253 events). Conclusion Targeting dynamic HDF sites is feasible and can be efficacious, but lacks specificity in identifying relevant human persAF substrate. Spectral organization may have an adjunctive role in preventing unnecessary substrate ablation. Dynamic HDF sites are not associated with observable rotational activity on isopotential mapping, but epi-endocardial breakthroughs could be contributory.
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Affiliation(s)
- Gavin S. Chu
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
| | - Xin Li
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
| | - Peter J. Stafford
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | | | - João L. Salinet
- Center for Engineering, Modeling and Applied Social Sciences, University Federal of ABC, Santo André, Brazil
| | - Tiago P. Almeida
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
| | - Nawshin Dastagir
- Department of International Foundation, Massey University, Auckland, New Zealand
| | - Alastair J. Sandilands
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Paulus Kirchhof
- University Heart and Vascular Centre, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fernando S. Schlindwein
- School of Engineering, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - G. André Ng
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
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8
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Beyond pulmonary vein isolation for persistent atrial fibrillation: sequential high-resolution mapping to guide ablation. J Interv Card Electrophysiol 2022; 65:53-62. [PMID: 35000099 PMCID: PMC9550675 DOI: 10.1007/s10840-021-01115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022]
Abstract
Purpose We aimed to evaluate whether outcomes with ablation in persistent (PsAF) and long-standing persistent (LsPsAF) AF can be improved beyond what can be achieved with pulmonary vein isolation (PVI) alone, using individualized mapping to guide ablation. Methods We studied 20 pts (15 M, 68 ± 11y) with PsAF (14) or LsPsAF (6) referred for first-time AF ablation. Following antral PVI, individualized mapping (IM) was performed using a high-density mapping catheter stably and fully deployed for 30 s at each of 23 ± 9 sites per patient. Activation data were reviewed, and an ablation strategy designed to intersect areas of focal and rotational activity. Mean follow-up was 429 ± 131 days. The study population was compared to a matched contemporary control cohort (CC) of 20 consecutive patients undergoing conventional ablation. Results Despite the IM group having a higher median comorbidities score, 3.5 vs. 2.5 in the CC group, indicating potentially more complex patients and more advanced substrate, cumulative freedom from AF after a single procedure was achieved in 94% of patients in the IM group vs. 75% in the CC group at 1 year and remained the same in both groups at the conclusion of the study (p = 0.02). There was a similar trend in atrial arrhythmia-free survival between both groups (84% vs. 67% at 1 year) that did not reach statistical significance. The procedure duration was longer in the IM group by a median of 31.5 min (p = 0.004). Conclusions Individualized mapping to guide AF ablation appears to achieve significantly greater AF-free survival compared to conventional PVI when applied as a primary ablation treatment. The results of this pilot study need to be confirmed in a larger, randomized trial. Supplementary Information The online version contains supplementary material available at 10.1007/s10840-021-01115-7.
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Quah JX, Dharmaprani D, Lahiri A, Tiver K, Ganesan AN. Reconceptualising Atrial Fibrillation Using Renewal Theory: A Novel Approach to the Assessment of Atrial Fibrillation Dynamics. Arrhythm Electrophysiol Rev 2021; 10:77-84. [PMID: 34401179 PMCID: PMC8335853 DOI: 10.15420/aer.2020.42] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/03/2021] [Indexed: 11/15/2022] Open
Abstract
Despite a century of research, the mechanisms of AF remain unresolved. A universal motif within AF research has been unstable re-entry, but this remains poorly characterised, with competing key conceptual paradigms of multiple wavelets and more driving rotors. Understanding the mechanisms of AF is clinically relevant, especially with regard to treatment and ablation of the more persistent forms of AF. Here, the authors outline the surprising but reproducible finding that unstable re-entrant circuits are born and destroyed at quasi-stationary rates, a finding based on a branch of mathematics known as renewal theory. Renewal theory may be a way to potentially unify the multiple wavelet and rotor theories. The renewal rate constants are potentially attractive because they are temporally stable parameters of a defined probability distribution (the exponential distribution) and can be estimated with precision and accuracy due to the principles of renewal theory. In this perspective review, this new representational architecture for AF is explained and placed into context, and the clinical and mechanistic implications are discussed.
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Affiliation(s)
- Jing Xian Quah
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia.,College of Science and Engineering, Flinders University of South Australia, Adelaide, SA, Australia
| | - Anandaroop Lahiri
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Kathryn Tiver
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Anand N Ganesan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
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10
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Schotten U, Lee S, Zeemering S, Waldo AL. Paradigm shifts in electrophysiological mechanisms of atrial fibrillation. Europace 2021; 23:ii9-ii13. [PMID: 33837750 DOI: 10.1093/europace/euaa384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/03/2020] [Indexed: 11/12/2022] Open
Abstract
Determining the sequence of activation is a major source of information for understanding the electrophysiological mechanism(s) of atrial fibrillation (AF). However, the complex morphology of the electrograms hampers their analysis, and has stimulated generations of electrophysiologists to develop a large variety of technologies for recording, pre-processing, and analysis of fibrillation electrograms. This variability of approaches is mirrored by a large variability in the interpretation of fibrillation electrograms and, thereby, opinions regarding the basic electrophysiological mechanism(s) of AF vary widely. Multiple wavelets, different types of re-entry including rotors, double layers, multiple focal activation patterns all have been advocated, and a comprehensive and commonly accepted paradigm for the fundamental mechanisms of AF is still lacking. Here, we summarize the Maastricht perspective and Cleveland perspective regarding AF mechanism(s). We also describe some of the key observations in mapping of AF reported over the past decades, and how they changed over the years, often as results of new techniques introduced in the experimental field of AF research.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Universiteitssingel 50 6229 ER, Maastricht, The Netherlands
| | - Seungyup Lee
- Department of Medicine, Cardiovascular Research Institute, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Universiteitssingel 50 6229 ER, Maastricht, The Netherlands
| | - Albert L Waldo
- Department of Medicine, Cardiovascular Research Institute, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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11
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Liao S, Ragot D, Nayyar S, Suszko A, Zhang Z, Wang B, Chauhan VS. Deep Learning Classification of Unipolar Electrograms in Human Atrial Fibrillation: Application in Focal Source Mapping. Front Physiol 2021; 12:704122. [PMID: 34393823 PMCID: PMC8360838 DOI: 10.3389/fphys.2021.704122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
Focal sources are potential targets for atrial fibrillation (AF) catheter ablation, but they can be time-consuming and challenging to identify when unipolar electrograms (EGM) are numerous and complex. Our aim was to apply deep learning (DL) to raw unipolar EGMs in order to automate putative focal sources detection. We included 78 patients from the Focal Source and Trigger (FaST) randomized controlled trial that evaluated the efficacy of adjunctive FaST ablation compared to pulmonary vein isolation alone in reducing AF recurrence. FaST sites were identified based on manual classification of sustained periodic unipolar QS EGMs over 5-s. All periodic unipolar EGMs were divided into training (n = 10,004) and testing cohorts (n = 3,180). DL was developed using residual convolutional neural network to discriminate between FaST and non-FaST. A gradient-based method was applied to interpret the DL model. DL classified FaST with a receiver operator characteristic area under curve of 0.904 ± 0.010 (cross-validation) and 0.923 ± 0.003 (testing). At a prespecified sensitivity of 90%, the specificity and accuracy were 81.9 and 82.5%, respectively, in detecting FaST. DL had similar performance (sensitivity 78%, specificity 89%) to that of FaST re-classification by cardiologists (sensitivity 78%, specificity 79%). The gradient-based interpretation demonstrated accurate tracking of unipolar QS complexes by select DL convolutional layers. In conclusion, our novel DL model trained on raw unipolar EGMs allowed automated and accurate classification of FaST sites. Performance was similar to FaST re-classification by cardiologists. Future application of DL to classify FaST may improve the efficiency of real-time focal source detection for targeted AF ablation therapy.
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Affiliation(s)
- Shun Liao
- Peter Munk Cardiac Centre, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Don Ragot
- Peter Munk Cardiac Centre, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sachin Nayyar
- Peter Munk Cardiac Centre, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Adrian Suszko
- Peter Munk Cardiac Centre, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Zhaolei Zhang
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Bo Wang
- Peter Munk Cardiac Centre, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Vijay S Chauhan
- Peter Munk Cardiac Centre, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Quintanilla JG, Shpun S, Jalife J, Filgueiras-Rama D. Novel approaches to mechanism-based atrial fibrillation ablation. Cardiovasc Res 2021; 117:1662-1681. [PMID: 33744913 PMCID: PMC8208747 DOI: 10.1093/cvr/cvab108] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/12/2021] [Accepted: 03/18/2021] [Indexed: 01/23/2023] Open
Abstract
Modern cardiac electrophysiology has reported significant advances in the understanding of mechanisms underlying complex wave propagation patterns during atrial fibrillation (AF), although disagreements remain. One school of thought adheres to the long-held postulate that AF is the result of randomly propagating wavelets that wonder throughout the atria. Another school supports the notion that AF is deterministic in that it depends on a small number of high-frequency rotors generating three-dimensional scroll waves that propagate throughout the atria. The spiralling waves are thought to interact with anatomic and functional obstacles, leading to fragmentation and new wavelet formation associated with the irregular activation patterns documented on AF tracings. The deterministic hypothesis is consistent with demonstrable hierarchical gradients of activation frequency and AF termination on ablation at specific (non-random) atrial regions. During the last decade, data from realistic animal models and pilot clinical series have triggered a new era of novel methodologies to identify and ablate AF drivers outside the pulmonary veins. New generation electroanatomical mapping systems and multielectrode mapping catheters, complimented by powerful mathematical analyses, have generated the necessary platforms and tools for moving these approaches into clinical procedures. Recent clinical data using such platforms have provided encouraging evidence supporting the feasibility of targeting and effectively ablating driver regions in addition to pulmonary vein isolation in persistent AF. Here, we review state-of-the-art technologies and provide a comprehensive historical perspective, characterization, classification, and expected outcomes of current mechanism-based methods for AF ablation. We discuss also the challenges and expected future directions that scientists and clinicians will face in their efforts to understand AF dynamics and successfully implement any novel method into regular clinical practice.
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Affiliation(s)
- Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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13
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Van Nieuwenhuyse E, Martinez-Mateu L, Saiz J, Panfilov AV, Vandersickel N. Directed graph mapping exceeds phase mapping in discriminating true and false rotors detected with a basket catheter in a complex in-silico excitation pattern. Comput Biol Med 2021; 133:104381. [PMID: 33901713 PMCID: PMC8204274 DOI: 10.1016/j.compbiomed.2021.104381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 12/04/2022]
Abstract
Atrial fibrillation (AF) is the most frequently encountered arrhythmia in clinical practise. One of the major problems in the management of AF is the difficulty in identifying the arrhythmia sources from clinical recordings. That difficulty occurs because it is currently impossible to verify algorithms which determine these sources in clinical data, as high resolution true excitation patterns cannot be recorded in patients. Therefore, alternative approaches, like computer modelling are of great interest. In a recent published study such an approach was applied for the verification of one of the most commonly used algorithms, phase mapping (PM). A meandering rotor was simulated in the right atrium and a basket catheter was placed at 3 different locations: at the Superior Vena Cava (SVC), the Crista Terminalis (CT) and at the Coronary Sinus (CS). It was shown that although PM can identify the true source, it also finds several false sources due to the far-field effects and interpolation errors in all three positions. In addition, the detection efficiency strongly depended on the basket location. Recently, a novel tool was developed to analyse any arrhythmia called Directed Graph Mapping (DGM). DGM is based on network theory and creates a directed graph of the excitation pattern, from which the location and the source of the arrhythmia can be detected. Therefore, the objective of the current study was to compare the efficiency of DGM with PM on the basket dataset of this meandering rotor. The DGM-tool was applied for a wide variety of conduction velocities (minimal and maximal), which are input parameters of DGM. Overall we found that DGM was able to distinguish between the true rotor and false rotors for both the SVC and CT basket positions. For example, for the SVC position with a CVmin=0.01cmms, DGM detected the true core with a prevalence of 82% versus 94% for PM. Three false rotors where detected for 39.16% (DGM) versus 100% (PM); 22.64% (DGM) versus 100% (PM); and 0% (DGM) versus 57% (PM). Increasing CVmin to 0.02cmms had a stronger effect on the false rotors than on the true rotor. This led to a detection rate of 56.6% for the true rotor, while all the other false rotors disappeared. A similar trend was observed for the CT position. For the CS position, DGM already had a low performance for the true rotor for CVmin=0.01cmms (14.7%). For CVmin=0.02cmms the false and the true rotors could therefore not be distinguished. We can conclude that DGM can overcome some of the limitations of PM by varying one of its input parameters (CVmin). The true rotor is less dependent on this parameter than the false rotors, which disappear at a CVmin=0.02cmms. In order to increase to detection rate of the true rotor, one can decrease CVmin and discard the new rotors which also appear at lower values of CVmin.
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Affiliation(s)
| | - Laura Martinez-Mateu
- Departamento de Teoría de La Señal y Las Comunicaciones y Sistemas Telemáticos y Computación, Universidad Rey Juan Carlos, Madrid, Spain
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Alexander V Panfilov
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium; Ural Federal University, Ekaterinburg, Russia; World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov University, Moscow, Russia
| | - Nele Vandersickel
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
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Fernandes LG, Seara FDAC. Heart rate variability for small animal veterinarians - A concise debate. BRAZILIAN JOURNAL OF VETERINARY MEDICINE 2021; 43:e003621. [PMID: 35749072 PMCID: PMC9179192 DOI: 10.29374/2527-2179.bjvm003621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/01/2021] [Indexed: 11/05/2022] Open
Abstract
This manuscript aims to provide a simple and concise discussion on heart rate variability (HRV) for small animal veterinarians. Despite the fact that heart rate variability analysis techniques have been used for quite a long time in medical sciences, it seems to be not completely understood by a large fraction of veterinarian professionals, thereby, reducing the possible benefits to patients that could arise from such information. The analysis of the R-R intervals enables the veterinarian to evaluate autonomic sympathetic and parasympathetic modulation of the heart, composing the so-called cardiac autonomic balance. Several pathophysiological states lead to profound changes in autonomic balance, especially in the cardiovascular system. Therefore, heart rate variability methods remain a valuable and powerful tool for the diagnosis and prognosis of cardiovascular diseases.
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Affiliation(s)
- Luciano Gonçalves Fernandes
- . Veterinarian, DSc., Departamento de Ciências Fisiológicas,Instituto de Ciências Biológicas e da Saúde, Universidade Federal Rural do Rio de Janeiro. Campus Seropédica - RJ, Brazil
- Correspondence Luciano Gonçalves Fernandes Departamento de Ciências Fisiológicas, Instituto de Ciências Biológicas e da Saúde, Universidade Federal Rural do Rio de Janeiro - UFRRJ Rodovia BR 465, Km 7, Campus Universitário, Bairro Zona Rural CEP 23897-000 - Seropédica (RJ), Brasil E-mail:
| | - Fernando de Azevedo Cruz Seara
- . Veterinarian, DSc., Departamento de Ciências Fisiológicas,Instituto de Ciências Biológicas e da Saúde, Universidade Federal Rural do Rio de Janeiro. Campus Seropédica - RJ, Brazil
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15
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Lee S, Waldo AL. Reply to the Editor-Reconsidering the reconsideration of the multiple wavelet hypothesis. Heart Rhythm 2020; 17:2221. [PMID: 32682808 DOI: 10.1016/j.hrthm.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Seungyup Lee
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Albert L Waldo
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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16
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Duchateau J, Pambrun T, Derval N. To the Editor-Reconsidering the reconsideration of the multiple wavelet hypothesis. Heart Rhythm 2020; 17:2221. [PMID: 32682807 DOI: 10.1016/j.hrthm.2020.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022]
Affiliation(s)
| | - Thomas Pambrun
- Hôpital Cardiologique du Haut Lévèque, CHU Bordeaux, Pessac, France
| | - Nicolas Derval
- Hôpital Cardiologique du Haut Lévèque, CHU Bordeaux, Pessac, France
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17
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Ganesan P, Narayan SM. Re-evaluating the multiple wavelet hypothesis for atrial fibrillation. Heart Rhythm 2020; 17:2219-2220. [PMID: 32673795 DOI: 10.1016/j.hrthm.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Prasanth Ganesan
- Cardiovascular Institute and Division of Cardiology, Stanford University, Stanford, California
| | - Sanjiv M Narayan
- Cardiovascular Institute and Division of Cardiology, Stanford University, Stanford, California.
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